Knee pain

Sri Yani
Anatomy
 A fibro-cartilaginous and wedge
shaped in the coronal plane
 The lateral meniscus is
connected to the femur via the
anterior (ligament of Humphrey)
and posterior (ligament of
Wrisberg) meniscofemoral
ligaments
 10% to 30% of the peripheral
medial meniscus border and 10%
to 25% of lateral meniscus
border receive irect blood supply
 Anatomy
 complex joint

 4 bones – 3 joints

 cartilage – 2
menisci

 ligaments

 muscles

The Knee
 Anatomy
 femur
 medial condyle
 trochlea: more proximal
lateral

 tibia
 medial plateau
 medial concave

 patella
 sesamoid bone
 lateral facet
The Knee
 PCL
Anatomy
 menisci
+/- avascular

 cartilage

ACL

The Knee
 Anatomy
 muscles
 …

 Bursae and plica

 suprapatellar
 medial
 mucosum

The Knee
 Anatomy
 muscles
 …

 bursae and
plicae
 suprapatellar
 medial
 mucosum

The Knee
four basic etiologies:

1. Osteoarthritis.
2. Ligament damage.
3. Meniscus damage.
4. Patellofemoral disorder.
History talking
1. Where is your pain?
 Pain at the joint line a collateral
ligament or meniscus problem (or both)
 Pain at the tibial tuberosity in a young
patient Osgood-Schlatter’s syndrome
 anterior knee pain patellofemoral
disorder
 pain over the medial tibial plateau,
approximately 2 inches below the joint
line pes anserinus bursitis
 Pain and swelling in the posterior knee
 a Baker’s cyst.
History talking
2. When did your pain begin,
what were you doing at the
time, and what were the
initial symptoms?
History talking
3. Do you experience any
grinding, locking, catching, or
giving way of the knee?
Grinding  characteristic of
osteoarthritis
locking and catching 
characteristic of meniscus injuries
and osteochondritis dissecans
Giving characteristic of
ligamentous injuries.
History talking
4. Are there any positions that
make your knee more or less
comfortable?
This question is specifically
targeting the diagnosis of
patellofemoral syndrome
”movie theater sign”
History talking
5. What is the quality of your pain
(sharp, shooting, dull, etc.)?
6. Have you tried anything to help
the pain and, if yes, has that been
successful?
7. Other important questions to
remember to ask include: Have
you ever had surgery on your
knee? Do you have any hip or
ankle pain (both hip and ankle
pain can refer pain to the knee,
and vice versa)?
Physical Exam
Traumatic  ottawa knee rule 
fraktur
◦ Pain on head of fibula dan local pain on
patella
◦ Patient can walk more than 2 step.
◦ Knee Flexion <900.
 Meniscus or ligament pathology
◦ Valgus injury?: Medial Collat lig. Medial
meniscus, medial joint capsel, cruciat lig.
◦ Varus injury? Lateral Collat lig. Lateral
meniscus, medial joint capsel, cruciat lig.
Temperature palpation

Use the dorsal of hand

Start on normal side
Palpate medial and
lateral
Palpate the other side
Observe swelling

See the sulcus

sign.
Hydrops
OTTAWA KNEE
RULES
Palpation on patella
◦ The test positive
when patient tell
painful
 Palpation of the
head of Fibulae
◦ The test positive
when patient tell
painful
Continue

Flexion of the
Knee
◦ Passive flexion of
the knee
Gait analysis:
◦ Canot walk more
then 2 step 
there is fracture
 Meniscus lesion: Mc
Murray test, Apply test
 Collateral lig.: Valgus –
varus test.
 Cruciat lig.: Drawer test.
(posterior/anterior straigth
stability test) positive if
condyle goes more
(dorsal/ventral) without
rotation.
 Hati2 ventro medial
/ventro lateral rotatory
instability
Stability test
 Drawer test with
rotation:
 Anterior
drawer test
with medial
rotation  ?
 Anterior
drawer test
with lateral
rotation  ?
 Posterior
drawer test
with medial
rotation  ?
 Posterior
Mc Muray Test
Medial meniscus
Palpate on the medial
joint line  tender spot
Start with flexion: is
there local pain at
dorsal knee?
Flexion of the knee
then Adduction ;
external rotation, do
patient feel pain on
medial side of the
knee?
Flexion of the knee
then Adduction ;
external rotation, do
patient feel pain on
medial side of the
knee?
Then extend the
knee till 900, do you
hear clicking? And
relief medial side
knee pain?
ANTERIOR DRAWER TEST
Position of the knee 900
◦ Look the patella and
tuberositas tibiae is in one
line?
Hand placing on the knee
Glide to anterior direction
(anterior straight stability)
◦ If feel tibia rotate to lateral 
anteromedial rotatory stability
◦ If feel tibia rotate to medial 
anterolateral rotatory stability
POSTERIOR DRAWER TEST
Hand placing on the
knee
Glide to posterior
direction (posterior
straight stability)
◦ If feel tibia rotate to
lateral  posteromedial
rotatory stability
◦ If feel tibia rotate to
medial  posterolateral
rotatory stability
VARUS TEST
Positionof therapist in
medial of patient’s leg
◦ In 300 flexi
◦ In zero degree
Ifpositive is Varus
Straight instability
VALGUS TEST
Position of
therapist in
lateral of patient
leg
◦ In 300 flexion
◦ In zero degree
If positive is
Valgus Straight
instability
PASSIVE TEST
Flexion

Extension
CONCLUTION
Joint mobilization Roll
slide :
Extension
◦ With anterior translation
Flexion
◦ With posterior translation
Instability problem
 Knee instability
Lig Laxity Muscle dysbalance Meniscus

Lig. Collateral medial Varus test

Passive & active
stabilization
Lig. Collateral lateral Valgus test

Lig. Cruciatum anterior Anterior shearing test

[Link] posterior Posterior shearing

test

Sugijanto
 PATHOLOGY

Patologi:
◦ Kelemahan ligament akibat
sprain/rupture saat oleh raga/kerja.
◦ Dapat terjadi pd lig. Collaterale
medial/lateral atau lig. Cruciatum
anterior/posterior.
 ASSESSMENT

Anamnesis
◦ Pain on knee flexion and extension
◦ Pain after or during activity

Inspeksi
◦ Kadang tampak genu valgus/varus
SPECIFIC TEST
Tes khusus
◦ Valgus test: [Link]
mediale
◦ Varus test: [Link]
laterale
◦ Anterior drawer test
[Link] anterior
◦ Posterior drawer test
[Link] posterior
Pemeriksaan lain
◦ Atroskopi
 INTERVENSION
Knee support dengan penguat pada
fungsi ligament yang lesi.
Latihan stabilisasi aktif. Pada posisi
MLPP.
Latihan Strengthening otot pes
anserinus (atau iliotibial, atau
hamstrings, atau quadriceps)
KNEE OSTEOARTHROSIS
 KNEE OSTEOARTHROSIS

Patologi:
◦ Degenerative joint disease
◦ Over used
◦ Overweight
Kerusakan rawan sendi mengeras
dan rapuh, terjadi erosi dan
fragmentasi, sebagian lepas sbg
corpus libera.
Nyeri  immobilisasi  capsule
contracture.
ASSESSMENT
Anamnesis
◦ Nyeri jenis ngilu/pegal pada Tibio
femoral joint
◦ Morning sickness dan start pain
◦ Gerak terbatas dan crepitasi
Inspeksi:
◦ Antalgic position dan antalgic gait
◦ Flexion contracture
PEMERIKSAAN FUNGSI
GERAK DASAR
Quick Test
◦ Nyeri dan terbatas pada fleksi,
ekstensi tibio femoral joint

◦ Nyeri dan terbatas dengan

crepitasi pada tibio femoral joint

Passive Test
◦ Nyeri dan terbatas dengan
crepitasi pada gerak tibio femoral
joint
◦ Fleksi, ekstensi, tibio femoral joint,
firm end feel.
Isometric Test
◦ Tidak ditemukan gangguan khas
 SPECIFIC TEST
Tes khusus
◦ JPM test fleksi, ekstensi tibio
femoral joint, firm end feel.
◦ Patello femoral test
◦ Ballotement test
◦ Fluktuation test
Pemeriksaan lain
◦ X ray: penyempitan sela sendi;
penebalan tulang subchondrale;
osteophyte.
 Knee Osteoarthrosis
Degenerasi

Over weight Over used Injury

Fragmentasi & Nyeri & kaku lutut Joint mobiliz

erosi rawan sendi
Antalgic gait
Muscle mobiliz
Hipertrofi
subchodr. & Rom: Flx < Ext
osteofit Firm end feel
Manipul corpus libera
Corpus libera
JPM: Nyeri akhir
Kontraktur
ROM / Firm end feel
Weight control
Joint blockade
Joint blockade
 CHONDROMALACIA
PATELLAE
• Patologi:
– Arthrosis patellofemoral
joint
– Genu valgum
– Kelemahan m. vastus
medialis
ASSESSMENT
Anamnesis
◦ Nyeri berjalan
◦ Deformitas kearah genu valgus
Inspeksi
◦ tidak tampak kelainan local.
Perhatikan Q angle/genu valgus
Q-angle
males is 10–15°,
females it is 10–
19°
 PEMERIKSAAN FUNGSI
GERAK DASAR
Tes cepat
◦ Gerakan flexi dan ekstensi terjadi
painfull arc
◦ Flexi dan ekstensi timbul crepitasi
patellae
Tes gerak pasif
◦ flexi dan ekstensi
Tes gerak isometric
◦ Gerak isometric ekstensi lutut nyeri
 TES KHUSUS
Tes khusus
◦ Palpasi : nyeri tekan pada condylus lateral
dan medial
◦ Joint play movement MLPP kompresi diatas
patella posisi lutut ekstensi dan semi fleksi.
◦ Pengukuran Q angle dan genu valgus.
◦ Tes kekuatan m. Vastus medialis.
Pemeriksaan lain
◦ ’X’ ray intuk melihat OA sendi
patellofemoralis
INTERVENSI
Transverse friction pd
posisi patella didorong
ke lateral dan medial
Strengthening exercise
m. Vastus medialis pada
posisi lutut gerak akhir
ekstensi
Medial arc support
(corect shoes)
 Chondromalacia
patellae
Degenerasi Genu valgus Lemah [Link]
Micro injury
medialis

Cidera trtm odd Nyeri patella

Medial wedge shoes
facet

Nyeri posisi 300

Erosi flex
Friction
Penebalan tl
subchondral Compression test
+ Strength [Link]
medialisn
Osteofit
Ballotement ±
Iritasi jar
 Knee pain with nerve
problem
Table 1
Primary Muscles and Innervation for Knee Movement

Major muscle
movement Primary muscles involved Primary innervation
Knee flexion Hamstrings Primarily tibial, but also
(semimembranosus, peroneal portion of

semitendinosus, biceps sciatic nerve

femoris). (primarily L5).
Knee extension Quadriceps (vastus Femoral nerve
lateralis, vastus medialis, (primarily L4).
vastus intermedius,
rectus femoris).
Knee extension against
resistance.
Knee flexion against
resistance.
Intervensi  waiting lumbar
problem
57